Psychiatric Disorders/Mental Health Status Examination
The purpose of this examination is to gather phenomenological data in an orderly way for purposes of diagnosis, checking of progress, note-taking, and communication.
It is largely based upon what a trained observer may see, and to a lesser extent upon what is described by the patient, although these must be combined. For instance, the comparison of affect, mood as reported by the patient, and countertransference phenomena is a key to the proper assessment of mood and psychotic disorders.
Notes about speech, language, and thought. In considering the mental state exam, speech may be confused with thought. The following definitions may assist:
Most correctly, speech is to be defined as the motor aspect of language. Speech would properly only be described according to articulation (how clearly each word is pronounced; slurring, running words together, etc.); anything else about utterances would be best categorized under Language or Thought.
Language is a system of symbols used to convey meaningful ideas. Language also includes how the ideas expressed fit in with the social situation: e.g. turn-taking. The neurology of language needs careful review by the student.
Thought and language are of course tightly linked concepts. Thought is the logical progression of ideas. Clearly the style of logic employed to link the ideas (the Form of thought) varies. Linkage may be only by sound, for instance: the so-called Klang association. e.g. "Mat, bat, cat."
The discussion below may be criticized as conflating speech with thought.
APPEARANCE
What does the patient look. like, smell like and sound like? Give a written description.
Self Neglect: cleanliness, shaven, make up, state of hair and clothes
Bizarre Appearance: secret documents openly displayed, special clothes or ornaments with symbolic significance, etc.
BEHAVIOUR
Involuntary movements: tics
Mannerisms
Stereotypes
Purposeful behaviour: pacing, fiddling
Congruity with the situation: does she act as if she understands the social conventions associated with the fact that she is being examined; e.g. when invited into the room, sits in what is obviously the examiner's chair.
RAPPORT
Includes Demeanour: threatening, seductive, friendly
AFFECT
Mood: inner emotional experience: can be inferred, but is best described
Affect: outer expression of mood
Level: elevated, lowered, euthymic
Range: restricted, increased, normal
Congruity: does the affect match what is being discussed?
Communicability: how readily does the observed affect and described mood cause a corresponding and similar feeling in the examiner? For instance, the moods of mania and depression are readily communicated. See Countertransference.
SPEECH
Slow Speech: Long pauses before answering, long pauses between words
Pressure of Speech: An increase in the amount of spontaneous speech as compared with what is considered ordinary or socially customary. The patient talks rapidly and is difficult to interrupt. Some sentences may be left uncompleted because of eagerness to get on to a new idea. Simple questions that could be answered at great length, so that the answer takes minutes rather than seconds and indeed may not stop at all if the speaker is not interrupted. Even when interrupted, the speaker often continues to talk. Speech tends to be loud and emphatic. Sometimes speakers with severe pressure will talk without any social stimulation and talk even though no one is listening. When patients are receiving phenothiazines or lithium carbonate, their speech is slowed down by medication, and then it can be judged only on the basis of amount, volume and social appropriateness. This disorder may be accompanied by derailment, tangentiality, or incoherence, but it is distinct from them.
Non Social Speech: Talks, mutters, whispers to self, out of context of conversation with examiner.
Muteness: Almost mute, (fewer than 20 words in all) Totally mute
Poverty of Speech (Poverty of Thought, Laconic Speech): Restriction in the amount of spontaneous speech, so that replies to questions tend to be brief, concrete, and unelaborated. Unprompted additional information is rarely provided. Replies may be monosyllabic, and some questions may be left unanswered altogether.
When confronted with this speech pattern, the interviewer may find himself frequently prompting the patient to encourage elaboration of replies. To elicit this finding, the examiner must allow the patient adequate time to answer and to elaborate his answer.
Example Interviewer "Do you think there is a lot of corruption in government?" Patient "Yeah seem to be" Interviewer "Do you think Haldeman and Ehrlichman and Mitchell have been fairly treated?" Patient "I don't know". Interviewer "Were you working at all before you came to the hospital?" Patient "No". Interviewer "What kind of jobs have you had in the past?" Patient "Oh some janitor jobs painting" Interviewer "What kind of work do you do?" Patient "I don't, don't like any kind of work.
That's silly". Interviewer "How far did you go in school?" Patient "I'm still in 11th grade". Interviewer "How old are you?" Patient "Eighteen”.
Neologisms: New word formation. A neologism is defined here as a completely new word or phrase whose derivation cannot be understood. Sometimes the term "neologism" has also been used to mean a word that has been incorrectly built up but with origins that are understandable as due to a misuse of the accepted methods of word formation. For purposes of clarity, these should be referred to as word approximations (discussed in the following section). Neologisms are quite uncommon.
Examples "I got so angry I picked up a dish and threw it at the geshinker". "So I sort of bawked the whole thing up".
Word Approximations (Paraphasia, Metonyms): Old words that are used in a new and unconventional way, or new words that are developed by conventional rules of work formation. Often the meaning will be evident even though the usage seems peculiar or bizarre (i.e.: gloves referred to as "handshoes", a ballpoint pen referred to as "paper skate" etc.). Sometimes the word approximations may be based on the use of stock words, so that the patient uses one or several words repeatedly in ways that give them a new meaning (i.e.: a watch may be called a "time vessel" the stomach a "food vessel" a television set a "news vessel" etc.). "One is called 'per God' and the other is called 'per the Devil"' miracle willed through God's 'turn horn' .... "Well, there is. a frequenting of clairvoyance ..." "Per God". "Per the Devil" and "turn horn" are neologisms; "frequenting of clairvoyance" is an example of ordinary words used idiosyncratically. Write down examples.
Disorder of Content of Speech: Three types of disordered content are specified: incoherence, flight of ideas and poverty. There are overlapping concepts and in each case, the effect is to make it very difficult to grasp what the patient means. However, the symptoms are defined in terms of specific components so that it should, in most cases, be possible to say whether one, two or all three symptoms are present. If in doubt, rate hierarchically; i.e., rate incoherence in preference to flight of ideas, and flight of ideas in preference to poverty of speech.
Incoherence of Speech: see Incoherence in section on Thought Form
Clanging: A pattern of speech in which sounds rather than meaningful relationships appear to govern word choice, so that the intelligibility of the speech is impaired and redundant words are introduced. In addition to rhyming relationships, this pattern of speech may also include punning associations, so that a word similar in sound brings in a new thought. Example "I'm not trying to make noise. I'm trying to make sense. If you can make sense out of nonsense, well, have fun. I'm trying to make sense out of sense. I'm not making sense (cents) anymore. I have to make dollars".
Poverty of Content of Speech (Poverty of Thought, Empty Speech, Alogia, Verbigeration, Negative Formal thought Disorder): Although replies are long enough so that speech is adequate in amount, it conveys little information. Language tends to be vague, often over abstract or over concrete, repetitive and stereotyped. The interviewer may recognise this finding_ by observing that the patient has spoken at some length but has not given adequate information to answer the question. Alternatively, the patient may provide enough information to answer the question, but require many words to do so, so that a lengthy reply can be summarised in a sentence or two.
Sometimes the interviewer may characterise the speech as "empty philosophising".
Exclusions This finding differs from circumstantially in that the circumstantial patient tends to provide a wealth of detail.
Example Interviewer "Tell me what you are like, what kind of person you are". Patient "Ah one hell of an odd thing to say perhaps in these particular circumstances, I happen to be quite pleased with who I am or how I am and many of the problems that I have and have been working on I have are difficult for me to handle or to work on because I am not aware of them as problems which upset me personally. I have to get my feelers way out to see how it is and where that what I may be or seem to be is distressing, too painful or uncomfortable to people who make a difference to me emotionally and personally or possibly on an economic or professional level. And I am I think becoming more aware that perhaps on an analogy the matter of some who understand or enjoy loud rages of anger, the same thing can be true for other people, and I have to kind of try to learn to see when that's true and what I can do about it".
Misleading Answers: Patient's answers are misleading because answers Yes or No to everything, or frequent self contradictions, or appears to be deliberately misleading. Do not include incoherence, flight of ideas or poverty of speech here.
Distractible Speech: During the course of a discussion or interview, the patient repeatedly stops talking in the middle of a sentence or idea and changes the subject in response to a nearby stimulus, such as an object on a desk, the interviewer's clothing or appearance, etc.
Example "Then I left San Francisco and moved to Where did you get that
tie? It looks like it's left over from the '50s. I like the warm weather in San Diego. Is that a conch shell on your desk? Have you ever gone scuba diving".
Stilted Speech: Speech that has an excessively stilted or formal quality. It may seem rather quaint or outdated, or may appear pompous, distant, or overpolite. The stilted quality is usually achieved through use of particular word choices (multisyllabic when monosyllabic alternatives are available and equally appropriate), extremely polite phraseology. ("Excuse me, madam, may I request a conference in your office at your convenience?"), or stiff and formal syntax ("Whereas the attorney comported himself indecorously, the physician behaved as is customary for a born gentleman").
Paraphasia, Phonemic: Recognisable mispronunciation of a word because sounds or syllables have slipped out of sequence. Severe forms occur in aphasia, milder forms may occur as "slips of the tongue" in everyday speech. The speaker often recognised his error and may attempt to correct it.
Example "I slipped on the lice and broke my arm while running to catch the bus"
Paraphasia, Semantic: Substitution of an inappropriate word during his effort to say something specific. The speaker may or may not recognise his error and attempt to correct it. It typically occurs in both Broca's and Wernicke's aphasia. It may be difficult to distinguish from incoherence, since incoherence may also be due to semantic substitutions that distort or obscure meaning.
INSIGHT
Does the patient know there is a problem; how does she assess her impairment, disability, and handicap due to the problem
how important is it to her;
does she want treatment;
how rational is her understanding of the problem and its treatment
COGNITIVE EXAMINATION
ORIENTATION
SPECIFIC TESTS
PHYSICAL EXAMINATION Special attention to:
the signs and causes of delirium
stigmata of drug use (acute: intoxication, and chronic, e.g. needle track marks, stigmata of alcohol and tobacco use) and abuse
stigmata of self harm, e.g. scars
general body habitus: obesity, degree of fitness
Neurological examination
COUNTERTRANSFERENCE
A term borrowed from psychoanalytic theory and practice, now used fairly generally to denote the therapist's own reactions to the interview. It is an essential part of the armamentarium of the therapist in all diagnostic and therapeutic encounters. Its components have been debated but may reasonably be said to include:
a) reactions arising from the therapist (such as empathy, sympathy, and thoughts, feelings, impulses etc. arising in the context of any state of mental health), and
b) mental states arising within, and communicated directly and literally from the patient. These may be experienced by the attuned therapist as unfamiliar, or not-self, although the distinction from one's own mental contents may be challenging even for experienced workers.
It will be apparent that the better a therapist knows him/herself, including his/her mental functioning and personality traits, the more valid a tool countertransference will be. Hence this tool, and one's general functioning as a psychiatrist, may be enhanced by a personal therapy.